Program reduces workers’ comp, disability 24%
Workplace violence in hospital targeted
When you’re having lunch with 1,000 dangerously mentally ill men, you really hope everyone has a good meal and walks away happy. Otherwise, a fork can be a deadly weapon.
Mealtime violence had become a major threat to patients and staff at Atascadero (CA) State Hospital for dangerous mentally ill men. The hospital has 1,700 staff and in just one year at the 1,000-bed psychiatric hospital, 134 staff members were injured through patient-related violence. Most of the injuries occurred at mealtimes and some were life-threatening. The facility recently won praise from the state occupational health department and a Codman award from the Joint Commission on the Accreditation of Healthcare Organizations for its innovative quality efforts in addressing a very serious problem.
Atascadero’s experience is being hailed as a good example of how occupational safety and health principles can be applied to violence in the workplace, a pervasive problem that recently has gained more attention from the Occupational Safety and Health Administration and other safety groups. A quarter of Atascadero’s nursing staff were suffering OSHA-reportable injuries from violence every year, says Colleen Carney Love, DNSc, RN, director of the clinical safety project.
"This is not a typically recognized occupational injury, but we decided to treat it as one because this is an industry in which violence is a daily risk for the staff," she says. "We needed to address the problem just as methodically as if we found that our employees were constantly hurting themselves in a physical task."
Once the hospital leaders decided to take decisive action against the problem, violent events in the dining room were reduced by 40% in one year. Attacks with silverware, the natural weapon of choice at mealtimes, were eliminated. By switching to plasticware, the facility also saved 70 nursing staff hours a day that had been devoted to silverware control procedures in the dining room, the equivalent of 14.5 full-time nursing staff positions per year.
The constant injuries cost the hospital an average of $766,290 per year, with each violence-related staff injury costing an average of $5,700 and 43 days of lost work, Carney Love says.
In addition, the violence reduction strategies contributed to a 24% reduction in the hospital’s workers’ compensation and industrial disability leave expenditures for fiscal year 1994/1995. The program has been so successful that the hospital received funding from the California Department of Industrial Relations for further research.
"The state occupational health department is used to dealing more with back injuries and slips and falls, but we submitted a grant request that used traditional occupational health strategies to reduce violence," she says. "We used the same principles of studying the risks, explaining them to workers, and crafting a response that included environmental changes, behavioral and policy changes, and employee education."
Quality assessment (QA) and total quality management (TQM) principles also were used to facilitate the improvements. Carney Love and others at Atascadero suggest the same approach could be used in other workplaces where violence is a threat. Though a hospital for the dangerously mentally ill may seem a unique setting, they say the same strategies could be applied in other settings. (For details on the strategies the team implemented, see box, at left.)
The turnaround required a new way of thinking at the facility, says Cindy Ramage, RN, the standards compliance coordinator. She and others at the facility put together a quality assessment team with instructions to take a hard look at the violence at the facility and take whatever steps necessary to reduce it. Mealtimes were clearly the most risky time for patients and staff, so that was the team’s first focus, Carney Love says.
"We’ve made it explicit that we won’t accept violence as part of the job, which is the way it’s been accepted in mental health," Carney Love says. "The issue of violence really is not addressed as vigorously as it should be in many settings, and this is an industry where it sometimes is just taken as a part of the workplace — something that had to be accepted."
The team already realized that mealtimes were an especially emotional time for psychiatric patients, with large groups brought together, often against their will, and required to follow certain procedures in order to eat. The logistics exacerbated stress levels that already were high, and often, patients exploded in rage.
Even though the problem was a familiar one, the team addressed it by first collecting data on exactly what sort of incidents were occurring. Without specific data, the team would not be able to develop effective solutions, says Carol Constien, RN, risk management coordinator.
"Mealtimes triggered a high level of incidents and the injuries from those incidents were much more severe than injuries that occurred elsewhere," she says. "We needed to know just how they were happening."
The team involved the patients in the solution because they were most directly involved and at high risk of injury. Their involvement was consistent with Atascadero’s whole philosophy of seeking patients’ input in their care and their environment. Patient representatives surveyed the patient population, providing valuable advice to administrators about realistic ways to reduce injuries. That turned out to be important when outside regulators came in and took a look at some of the changes.
"When we told them we were going to switch to plasticware, there was a negative reaction because, from an outside perspective, that seems less normalized," Carney Love says. "But we were able to show that the patients themselves supported the move. Patient anxiety is a lot lower now that the person across the table just has a plastic fork when he gets angry, not a whole complement of silverware in his hands."
Sources
For more information on workplace violence, contact:
• Atascadero State Hospital, P.O. Box 7001, Atascadero, CA 93423. Telephone: (805) 468-2008.
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